Provider Demographics
NPI:1083970545
Name:LIFE MASTER LLC
Entity Type:Organization
Organization Name:LIFE MASTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MITZI
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, CLSW, MPH
Authorized Official - Phone:808-737-6277
Mailing Address - Street 1:2957 KALAKAUA AVENUE
Mailing Address - Street 2:SUITE 601
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96815
Mailing Address - Country:US
Mailing Address - Phone:808-737-6277
Mailing Address - Fax:
Practice Address - Street 1:2957 KALAKAUA AVE
Practice Address - Street 2:SUITE 601
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96815-4650
Practice Address - Country:US
Practice Address - Phone:808-737-6277
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-09
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI663103T00000X
HI31051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI55077401Medicaid